Date

Birth Date

Age

Steve@ohministries.org

PLEASE PLACE THIS EMAIL IN THE BOX BELOW

Gender

Phone Number*

Cell Phone Number

Address

City

State

Zip Code

Marital Status

Military

Military Branch

Occupation

Buisness Phone

Email Address

Last Grade Completed Prior To College

Other Education (List type and Years)

Referred By*

Appointment Availability

The Basic Problem As You Understand It

Briefly complete the following (please use additional paper or back of form if necessary)

Please Describe the Current Problem

What have you done about it?

What are your expectations in coming here?

What led you to seek help now?

As you see yourself, what kind of person are you? Describe yourself

Is there any other info we should know?

Your Spiritual Life

Describe Below

May we contact your pastor?

Please Initial

Church Attendance: Frequency of attendance

Please List Times Per Month Below

Are you a Member?

If yes, how long?

Church attended in childhood

What are you learning through sermons/messages/bible studies at your church?

Please List Ministry Involvement

Have you been baptized?

When?

If married, religious background of spouse:

(Only if applicable) Spouse's church attendance

Describe Below

Spouse's Church Name

Frequency of attendance

Please List Times Per Month

Do you pray to God?

How often?

What do you pray about?

Have you come to a place in your spiritual life where you know with certainity that if you were to die tonight you would go to heaven?

If yes, what is your basis for answering the question above?

Have you recieved Jesus Christ personally as your savior?

Yes, No, Uncertain, Don't know what you mean?

If Answered Yes to the above question explain When?

If Yes, please answer questions 1-3 below

How do you know that Jesus Christ is your Savior?

What changes took place in your life when you became a believer?

Have you told household/family members about recieving Jesus as Savior?

If yes, who have you told?

Do you read the Bible?

How often?

Do you have personal devotions?

How often?

Describe your personal devotions

Do you have family devotions?

How often?

Explain any recent changes in your spirtual life?

Information about Prior Counseling

Have you had counseling before?

Counselor Name (s) Dates: To-From Medication Outcome and Diagnosis Prescribed

May we contact your counselor (s)?

Please Initial Below

Information about Personal Habits and Health

Approximately how many hours of sleep do you get each night?

When do you normally?:

Go to bed? Fall asleep? Wake up? Get out of bed?

If there is a length of time between going to bed adn falling asleep, what do you do during that time?

If there is a length of time between waking up and getting out bed, what do you do during that time?

Describe any recent changes in sleep habits?

State of Health

Date of Last Medical Examination

Results

Physicians Name

Address

Are you presently?

What? and Dosage?

Use Extra Paper or Back of Form to list medications if needed

For what reason do you take this medicaton?

Have you used drugs for other than medical purposes?

When? and What?

Amount/Dosages?

Do you drink alcoholic beverages?

How often?

How much?

Have you ever been arrested?

What was the outcome?

Have you ever had a severe emotional upset?

List all important present or past illnesses, injuries or handicaps

Weight Changes Recently:

Lost And Gained

Marriage and Family Information

Name of Spouse

Address

City

Zip Code

Phone Number

Buisness Phone Number

Occupation

Your Spouse's Age

Education in year(s)

Religion

Is your spouse willing to come with you?

Are you currently separated?

Since When?

Have you ever been separated in the current marriage?

Number of times

Has either of you ever filed for divorce?

When?

Who?

Date of Marriage

Your ages when married?

Husband And Wife

How long did you know your spouse before marriage?

Length of steady dating with spouse

Length of engagement

Have you been married before?

If yes, how many times?

Husband Wife

If you or your spouse were married before, how did the marriages end?

Children's Living

Names, Ages, Genders

check this column if child is by previous marriage

If you were raised by anyone other than your parents briefly explain

Number of Older Brothers And Sisters

Number of Younger Brothers and Sisters

COUNSELING DONATION

I do NOT receive a salary or pay of any kind. A DONATION of $40 or more to OPEN HEARTS MINISTRIES is asked This is a TAX DEDUCTIBLE DONATION PAYABLE BY CASH, CHECK OR CREDIT CARD

STATEMENT OF AGREEMENT/ COUNSELING TERMS

I/We affirm the accuracy of the personal information provided herein, have read the information and agree to the conditions set forth therein. I/We hereby agree to the following conditions: 1. I am (We are) committed to seeking new insights into a personal, love relationship with Jesus Christ, which may involve new understandings from God’s Word, and to pursuing a transformed life (lives) that reflects) God’s grace as revealed in His Word. 2. I (We) will fulfill the weekly assignments or the session might not be held. 3. I (We) will consistently attend a Biblebelieving church each Sunday while I am (we are) in counseling. 4. I (We) will keep the appointment time, or will call to cancel 24 hours in advance. (Except for absolute emergencies)

Healing hearts Counseling Ministries Additional Counseling Information Confidentiality Agreement

Confidentiality is an important aspect of the counseling process. We carefully guard the information you entrust to us to the fullest extent possible. There are exceptions when counseling information may be shared outside the Healing Hearts counseling context . Those exceptions would include, but are not limited to the following: (1) known or suspected child abuse or elderly abuse of any kind; (2) the intent to take criminal actions or violence against another person; (3) active suicidal thoughts or intentions; and; ( 4 ) other credible intent to harm self or others; and (5 ) matters of church discipline (see Matthew 18:1517). Counselors reserve the right and discretion to contact any and all appropriate entities when, as a result of the counseling, it is clear that a crime has been committed or is about to be committed or the safety and welfare of any person (including the counselee) is in jeopardy. The counselor is not required to notify the counselee in advance of any such contact with the appropriate entities. In the case of marriage or family counseling, there is limited confidentiality, meaning the confidentiality belongs to the relationship and not to the individual .

Where do I go?

Healing Hearts Counseling Office 611 N. College Ave. ElDorado, AR 71730 (At the corner of Grove and College in the A-PLUS Insurance Office Building.) What should I bring? bring your Bible and a notebook to each appointment.

Do you have childcare? We do not have facilities for childcare.

Having clearly stated the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body. If you have . If these guidelines are acceptable to you, please sign below. Signed Bro. Steve EMAIL….. steve@ohministries.org

I have read and understood the policies stated above, and I consent to abide by them.

Print your name: _____________________________________________________ Signed: _____________________________________ Date: __________________ Counselor: __________________________________ Date: __________________ Assistant Counselor: __________________________ Date: __________________

Intake Application